Chapter 141. Tinea Versicolor

A young black man presents to the office with a 5-year history of white spots on his trunk (Figure 141-1). He denies any symptoms but worries if this could spread to his girlfriend. These spots get worse during the summer months but never go away completely. He was relieved to receive a treatment for his tinea versicolor and to find out that it is rarely spread to others through contact.

Tinea versicolor is a common superficial skin infection caused by the dimorphic lipophilic yeast Pityrosporum (Malassezia furfur). The most typical presentation is a set of hypopigmented macules and patches with fine scale over the trunk in a cape-like distribution.

Pityriasis versicolor is actually a more accurate name as “tinea” implies a dermatophyte infection. Tinea versicolor is caused by Pityrosporum and not a dermatophyte.

• Seen more commonly in men than in women.
• Seen more often during the summer, and is especially common in warm and humid climates.

• Tinea versicolor is caused by Pityrosporum (M. furfur), which is a lipophilic yeast that can be normal human cutaneous flora.
• Pityrosporum exists in two shapes—Pityrosporum ovale (oval) and Pityrosporum orbiculare (round).
• Tinea versicolor starts when the yeast that normally colonizes the skin changes from the round form to the pathologic mycelial form and then invades the stratum corneum.1
• Pityrosporum is also associated with seborrhea and Pityrosporum folliculitis.
• The white and brown colors are secondary to damage caused by the Pityrosporum to the melanocytes, while the pink is an inflammatory reaction to the organism.
• Pityrosporum thrive on sebum and moisture; they tend to grow on the skin in areas where there are sebaceous follicles secreting sebum.

Clinical Features

Tinea versicolor consists of hypopigmented, hyperpigmented, or pink macules and patches on the trunk that are finely scaling and well-demarcated. Versicolor means a variety of or variation in colors; tinea versicolor tends to come in white, pink, and brown colors (Figures 141-1, 141-2, 141-3, 141-4, 141-5).

Typical Distribution

Tinea versicolor is found on the chest, abdomen, upper arms, and back, whereas seborrhea tends to be seen on the scalp, face, and anterior chest.

Laboratory Studies

A scraping of the scaling portions of the skin may be placed onto a slide using the side of another slide or a scalpel. KOH with DMSO (DMSO helps the KOH dissolve the keratinocytes faster and reduces the need for heating the slide) is placed on the slide and covered with a coverslip. Microscopic examination reveals the typical “spaghetti-and-meatballs” pattern of tinea versicolor. The “spaghetti”, or more accurately “ziti”, is the short mycelial form and the “meatballs” are the round yeast form (Figures 141-6 and 141-7). Fungal stains such as the Swartz-Lamkins stain help make the identification of the fungal elements easier.

• Pityriasis rosea has a fine collarette scale around the border of the lesions and is frequently seen with a herald patch. Negative KOH (see Chapter 153, Pityriasis Rosea).
• Secondary syphilis is usually not scaling and tends to have macules on the palms and soles. Negative KOH (see Chapter 216, Syphilis).
• Tinea corporis is rarely as widespread as tinea versicolor and each individual lesion usually has central clearing and a well-defined, raised, scaling border. The KOH preparation in tinea corporis shows hyphae with multiple branch points and not the “ziti-and-meatballs” pattern of tinea versicolor (see Chapter 138, Tinea Corporis).
• Vitiligo—The degree of hypopigmentation is greater and the distribution is frequently different with vitiligo involving the hands and face (see Chapter 198, Vitiligo).
• Pityriasis alba—Lightly hypopigmented areas with slight scale that tend to be found on the face and trunk of children with atopy. These patches are frequently smaller and rounder than tinea versicolor (see Chapter 145, Atopic Dermatitis).
• Pityrosporum folliculitis is caused by the same organism but presents with pink or brown papules on the back. The patient complains of itchy rough skin and the KOH is positive (Figure 141-8).

Topical

• Because tinea versicolor is usually asymptomatic, the treatment is mostly for cosmetic reasons.
• The mainstay of treatment has been topical therapy using antidandruff shampoos, because the same Pityrosporum species that cause seborrhea and dandruff also cause tinea versicolor.1,2
• Patients may apply selenium sulfide 2.5% lotion or shampoo, or zinc pyrithione shampoo to the involved areas daily for 1 to 2 weeks. Various amounts of time are suggested to allow the preparations to work, but there are no studies that show a minimum exposure time needed. A typical regimen involves applying the lotion or shampoo to the involved areas for 10 minutes and then washing it off in the shower. SOR C
• One study used ketoconazole 2% shampoo (Nizoral) as a single application or daily for 3 days and found it safe and highly effective in treating tinea versicolor.3 SOR B
• Topical antifungal creams for smaller areas of involvement can include ketoconazole and clotrimazole. SOR C

• A single-dose 400-mg oral fluconazole provided the best clinical and mycologic cure rate, with no relapse during 12 months of follow-up.4 SOR B
• A single dose of 300 mg of oral fluconazole repeated weekly for 2 weeks was equal to 400 mg of ketoconazole in a single dose repeated weekly for 2 weeks. No significant differences in efficacy, safety, and tolerability between the two treatment regimens were found.5 SOR B
• A single-dose 400-mg oral ketoconazole to treat tinea versicolor is safe and cost-effective compared to using the newer, more expensive, oral antifungal agents, such as itraconazole.6,7 SOR B
• Oral itraconazole 200 mg given twice a day for 1 day a month has been shown to be safe and effective as a prophylactic treatment for tinea versicolor.8 SOR B
• There is no evidence that establishes the need to sweat after taking oral antifungals to treat tinea versicolor.

Patients should be told that the change in skin color will not reverse immediately. The first sign of successful treatment is the lack of scale. The yeast acts like a sunscreen in the hypopigmented macules. Sun exposure will hasten the normalization of the skin color in patients with hypopigmentation.

None needed unless it is a stubborn or recurrent case. Recurrent cases can be treated with monthly topical or oral therapy.

Patient Resources

• http://www.skinsight.com/adult/tineaVersicolor.htm.

Provider Resources

• http://emedicine.medscape.com/article/1091575.